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Inspection visit

Health inspection

PEARL OF ELGIN, THECMS #1458211 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

145821 10/17/2024 Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to timely respond to a resident's Power of Attorney after being notified of a concern with a resident's damaged hearing aids. The facility failed to follow their grievance policy. This applies to 1 of 6 residents (R1) reviewed for grievances. The findings include: R1's EMR (Electronic Medical Record) showed R1 had hearing impairment and required the use of bilateral hearing aids. R1's MDS (Minimum Data Set) dated 8/17/2024 showed R1 had moderate cognitive impairment. On 10/15/2024 at 11:55 AM, V6 (Admissions Director) said she received an email on 7/30/2024 from an outside provider regarding V13's (R1's Power of Attorney/POA) concern of R1's missing hearing aids that were found damaged. V6 continued to say she then received another email on 8/03/2024 from V13 regarding her concern with R1's damaged hearing aids and a request to have the facility contact her. V6 said she informed the facility's management team, including V1 (Administrator), on 8/03/2024. On 10/16/2024 at 12:30 PM, V1 (Administrator) said during R1's last care plan meeting on 9/19/2024, V13 again expressed her concern regarding R1's damaged hearing aids. V1 said V13's concern had not been addressed prior because they were informed by an outside provider that R1 possibly damaged her hearing aids herself and then V13 had provided R1 with new hearing aids on 7/25/2024. V1 said the facility did not investigate or interview staff regarding R1's alleged hearing aid incident. The facility's email correspondence from V13 to the facility dated 8/03/2024, showed V13 notified V6 of her concern regarding R1's damaged hearing aids and requested for the facility to contact her. R1's Grievance Concern/Lost Item Form regarding R1's damaged hearing aids was filed on 9/19/2024, which showed a total of 51 days had passed from when the facility was initially notified of R1's concern. The facility's policy titled Grievance Program dated 5/15/2024, said Policy Statement To promote an environment and culture open to feedback positive and or negative from residents, family members, employees, physicians, and any other visitors. Definition: A grievance is a concern that cannot be resolved to the satisfaction of the person making the objection at the bedside and or immediately. Immediately: For the sake of this document, immediately is defined as within four or less hours. 2. Process .When there is a grievance it will be: i. Document on the facility Grievance Report. ii. Routed to the Grievance Officer. iii. Listed on the facility Grievance Tracking Log. iv. Discussed with Page 1 of 2 145821 145821 10/17/2024 Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123
F 0585 appropriate individuals .as warranted. v. Investigated accordingly . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145821 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0585GeneralS&S Dpotential for harm

    F585 - Grievances

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

FAQ · About this visit

Common questions about this visit

What happened during the October 17, 2024 survey of PEARL OF ELGIN, THE?

This was a inspection survey of PEARL OF ELGIN, THE on October 17, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PEARL OF ELGIN, THE on October 17, 2024?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grie..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.